Provider First Line Business Practice Location Address:
750 W USTICK RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-376-0660
Provider Business Practice Location Address Fax Number:
208-376-0350
Provider Enumeration Date:
03/06/2009