Provider First Line Business Practice Location Address:
3223 E LOUISE AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-0200
Provider Business Practice Location Address Fax Number:
208-648-4086
Provider Enumeration Date:
04/21/2018