Provider First Line Business Practice Location Address:
845 E FAIRVIEW AVE STE 120
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:
83642-8048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-6283
Provider Business Practice Location Address Fax Number:
208-887-7759
Provider Enumeration Date:
04/19/2011