Provider First Line Business Practice Location Address:
800 S INDUSTRY WAY STE 330
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:
83642-3598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-287-3733
Provider Business Practice Location Address Fax Number:
208-258-6756
Provider Enumeration Date:
12/09/2013