Provider First Line Business Practice Location Address:
2347 E GALA
Provider Second Line Business Practice Location Address:
SUITE 150
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:
208-345-3530
Provider Business Practice Location Address Fax Number:
208-381-5080
Provider Enumeration Date:
06/27/2006