Provider First Line Business Practice Location Address:
2065 E. FAIRVIEW AVE.
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:
83642-5798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-955-7491
Provider Business Practice Location Address Fax Number:
208-955-7492
Provider Enumeration Date:
03/04/2009