Provider First Line Business Practice Location Address:
2058 E FRANKLIN RD STE 110
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:
83642-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-286-2124
Provider Business Practice Location Address Fax Number:
208-855-5915
Provider Enumeration Date:
03/13/2007