Provider First Line Business Practice Location Address:
2204 E LANARK ST STE 100
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:
83642-5916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-908-7907
Provider Business Practice Location Address Fax Number:
208-908-7935
Provider Enumeration Date:
12/08/2006