Provider First Line Business Practice Location Address:
1270 E FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-1844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-5460
Provider Business Practice Location Address Fax Number:
208-288-2844
Provider Enumeration Date:
03/26/2010