Provider First Line Business Practice Location Address:
4740 N. PENNGROVE WAY
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-3663
Provider Business Practice Location Address Fax Number:
208-938-3664
Provider Enumeration Date:
07/10/2006