Provider First Line Business Practice Location Address:
600 E WATERTOWER ST
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-6287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-376-3800
Provider Business Practice Location Address Fax Number:
208-376-3810
Provider Enumeration Date:
06/03/2006