Provider First Line Business Practice Location Address:
1380 E GRIFFON 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:
83642-7473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-861-1223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2007