Provider First Line Business Practice Location Address:
2321 E GALA ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-7692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-5848
Provider Business Practice Location Address Fax Number:
208-888-0884
Provider Enumeration Date:
06/12/2014