Provider First Line Business Practice Location Address:
205 E WATERTOWER 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:
83642-6282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-914-2230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2013