Provider First Line Business Practice Location Address:
2275 SO EAGLE RD
Provider Second Line Business Practice Location Address:
SUTE 160
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-947-2266
Provider Business Practice Location Address Fax Number:
208-947-2267
Provider Enumeration Date:
11/11/2008