Provider First Line Business Practice Location Address:
1626 S WELLS AVE STE 105
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:
83642-4528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-789-0200
Provider Business Practice Location Address Fax Number:
208-288-2784
Provider Enumeration Date:
05/25/2023