Provider First Line Business Practice Location Address:
745 S PROGRESS AVE STE 150
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:
83642-5610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-813-1958
Provider Business Practice Location Address Fax Number:
208-600-6905
Provider Enumeration Date:
02/09/2023