Provider First Line Business Practice Location Address:
750 W USTICK RD STE 120
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:
83646-6133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-273-9521
Provider Business Practice Location Address Fax Number:
208-502-2538
Provider Enumeration Date:
09/06/2011