Provider First Line Business Practice Location Address:
1550 E HERITAGE PARK ST STE 100
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:
83642-5886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-5556
Provider Business Practice Location Address Fax Number:
208-884-4041
Provider Enumeration Date:
08/02/2006