Provider First Line Business Practice Location Address:
2893 E GREEN CANYON DR
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:
83642-9105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-850-6511
Provider Business Practice Location Address Fax Number:
208-888-3882
Provider Enumeration Date:
11/30/2006