Provider First Line Business Practice Location Address:
1850 E. FAIRVIEW AVE.
Provider Second Line Business Practice Location Address:
1850 E. FAIRVIEW AVE.
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-5273
Provider Business Practice Location Address Fax Number:
208-887-5267
Provider Enumeration Date:
04/05/2011