Provider First Line Business Practice Location Address:
5390 N MCDERMOTT RD
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:
83646-2594
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-877-1513
Provider Business Practice Location Address Fax Number:
208-877-1713
Provider Enumeration Date:
07/22/2021