Provider First Line Business Practice Location Address:
1303 E CENTRAL DR.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-4500
Provider Business Practice Location Address Fax Number:
208-350-5964
Provider Enumeration Date:
03/26/2007