Provider First Line Business Practice Location Address:
2596 N STOKESBERRY PL
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-3837
Provider Business Practice Location Address Fax Number:
208-938-3857
Provider Enumeration Date:
04/01/2006