Provider First Line Business Practice Location Address:
4660 N PENNGROVE WAY STE 110
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:
83646-8042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-2992
Provider Business Practice Location Address Fax Number:
208-938-3476
Provider Enumeration Date:
06/30/2006