Provider First Line Business Practice Location Address:
3081 S GRIMES CREEK 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:
83642-9125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-2264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2014