Provider First Line Business Practice Location Address:
1672 S WOODSAGE AVE STE 120
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:
83642-8332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-515-2273
Provider Business Practice Location Address Fax Number:
208-515-2274
Provider Enumeration Date:
02/20/2025