Provider First Line Business Practice Location Address:
3667 N LOCUST GROVE 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:
83646-5924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-971-9333
Provider Business Practice Location Address Fax Number:
541-926-4891
Provider Enumeration Date:
12/12/2025