Provider First Line Business Practice Location Address:
240 W LAVA FALLS 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:
83646-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-629-9845
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2026