Provider First Line Business Practice Location Address:
2512 N STOKESBERRY PL STE 102
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:
83646-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-229-3238
Provider Business Practice Location Address Fax Number:
208-880-4245
Provider Enumeration Date:
12/13/2006