Provider First Line Business Practice Location Address:
2825 S MERIDIAN RD STE 150
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:
83642-7960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-412-5128
Provider Business Practice Location Address Fax Number:
208-955-2490
Provider Enumeration Date:
01/30/2020