Provider First Line Business Practice Location Address:
1672 S WOODSAGE AVE BLDG C
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:
83642-8329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-248-4683
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2026