Provider First Line Business Practice Location Address:
3610 W LAMONT 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:
83642-6430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-391-7811
Provider Business Practice Location Address Fax Number:
208-493-9900
Provider Enumeration Date:
02/03/2023