Provider First Line Business Practice Location Address:
2264 E CINEMA 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:
83642-8249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-0262
Provider Business Practice Location Address Fax Number:
208-429-8575
Provider Enumeration Date:
02/10/2025