Provider First Line Business Practice Location Address:
3025 WEST CHERRY LANE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-8550
Provider Business Practice Location Address Fax Number:
208-367-8555
Provider Enumeration Date:
05/20/2006