Provider First Line Business Practice Location Address:
943 W. OVERLAND RD.
Provider Second Line Business Practice Location Address:
STE 126
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-926-2046
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2006