Provider First Line Business Practice Location Address:
2320 E GALA ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-898-0304
Provider Business Practice Location Address Fax Number:
208-898-0380
Provider Enumeration Date:
06/15/2006