Provider First Line Business Practice Location Address:
2365 E GALA ST
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-4881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-1920
Provider Business Practice Location Address Fax Number:
208-288-2844
Provider Enumeration Date:
12/11/2006