Provider First Line Business Practice Location Address: 
4795 N SUMMIT WAY STE 120
    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: 
83646-5017
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-888-0662
    Provider Business Practice Location Address Fax Number: 
208-888-0863
    Provider Enumeration Date: 
06/30/2008