Provider First Line Business Practice Location Address:
3875 E OVERLAND RD STE 204
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:
83642-9048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-3652
Provider Business Practice Location Address Fax Number:
208-367-9188
Provider Enumeration Date:
07/18/2007