Provider First Line Business Practice Location Address:
660 E FRANKLIN RD STE 110
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:
83642-2912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-2393
Provider Business Practice Location Address Fax Number:
208-895-2641
Provider Enumeration Date:
02/08/2006