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