Provider First Line Business Practice Location Address:
1302 E GREEN HAVEN ST
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:
83646-5935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-9133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2006