Provider First Line Business Practice Location Address:
2512 N STOKESBERRY PL STE 101
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:
83646-1144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-639-1122
Provider Business Practice Location Address Fax Number:
208-639-1921
Provider Enumeration Date:
10/25/2009