Provider First Line Business Practice Location Address:
1550 N CRESTMONT DR STE E
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:
83642-2177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-4200
Provider Business Practice Location Address Fax Number:
208-288-4279
Provider Enumeration Date:
06/09/2015