Provider First Line Business Practice Location Address:
2525 N STOKESBERRY PL
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-321-4166
Provider Business Practice Location Address Fax Number:
208-321-4167
Provider Enumeration Date:
07/06/2009