Provider First Line Business Practice Location Address:
1209 N SUMMERBROOK AVE 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:
83642-8750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-5823
Provider Business Practice Location Address Fax Number:
208-938-5306
Provider Enumeration Date:
03/01/2006