Provider First Line Business Practice Location Address:
1304 W CLARINDA ST
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:
83642-4373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-410-1799
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2026