Provider First Line Business Practice Location Address:
3814 W NEWLAND ST
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-981-4339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2026