Provider First Line Business Practice Location Address:
1005 E FRANKLIN RD
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:
83642-5951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-9302
Provider Business Practice Location Address Fax Number:
208-855-9303
Provider Enumeration Date:
12/14/2015