Provider First Line Business Practice Location Address:
2960 E ST LUKES ST STE 200
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:
83642-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-208-1234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2024