Provider First Line Business Practice Location Address:
5155 S HILLSDALE AVE
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:
83642-7587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-2222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2026