Provider First Line Business Practice Location Address:
903 N MAIN 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:
83642-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-4747
Provider Business Practice Location Address Fax Number:
208-887-4657
Provider Enumeration Date:
02/16/2016