Provider First Line Business Practice Location Address:
1226 E 2 1/2 ST
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:
83642-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-813-6167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2012