Provider First Line Business Practice Location Address:
1620 S CELEBRATION AVE
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:
83642-2779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-1030
Provider Business Practice Location Address Fax Number:
208-884-3058
Provider Enumeration Date:
05/05/2006