Provider First Line Business Practice Location Address:
366 SW 5TH AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-898-9755
Provider Business Practice Location Address Fax Number:
208-898-2544
Provider Enumeration Date:
02/20/2024