Provider First Line Business Practice Location Address:
3611 N LOCUST GROVE RD STE B
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:
83646-5924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-918-9198
Provider Business Practice Location Address Fax Number:
208-914-7641
Provider Enumeration Date:
02/06/2012