Provider First Line Business Practice Location Address:
1494 W. USTICK RD.
Provider Second Line Business Practice Location Address:
110
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-908-7797
Provider Business Practice Location Address Fax Number:
208-908-6588
Provider Enumeration Date:
04/19/2012