Provider First Line Business Practice Location Address:
2951 W HIGAN ST
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:
83646-4106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-608-1233
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2025