Provider First Line Business Practice Location Address:
1570 E HERITAGE PARK STREET
Provider Second Line Business Practice Location Address:
SUITE 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:
208-884-8066
Provider Business Practice Location Address Fax Number:
208-884-4809
Provider Enumeration Date:
10/23/2006