Provider First Line Business Practice Location Address:
4334 N BRIGHT ANGEL AVE
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:
83646-3611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-376-7298
Provider Business Practice Location Address Fax Number:
208-377-8310
Provider Enumeration Date:
10/27/2025