Provider First Line Business Practice Location Address:
2498 N. STOKESBERRY PL.
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-403-7488
Provider Business Practice Location Address Fax Number:
208-529-1960
Provider Enumeration Date:
02/28/2008