Provider First Line Business Practice Location Address: 
3653 N LOCUST GROVE RD
    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: 
83646-5924
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-338-5437
    Provider Business Practice Location Address Fax Number: 
208-939-9811
    Provider Enumeration Date: 
04/09/2007