Provider First Line Business Practice Location Address:
1406 N MAIN ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-1795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-6123
Provider Business Practice Location Address Fax Number:
208-888-6482
Provider Enumeration Date:
09/21/2006