Provider First Line Business Practice Location Address:
2960 E. ST LUKE'S ROAD
Provider Second Line Business Practice Location Address:
SUITE 200
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:
208-615-3847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2026