Provider First Line Business Practice Location Address:
680 S PROGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-8686
Provider Business Practice Location Address Fax Number:
208-895-8975
Provider Enumeration Date:
07/07/2005