Provider First Line Business Practice Location Address:
3525 E. LOUISE DR. SUITE 500
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-994-1934
Provider Business Practice Location Address Fax Number:
208-473-5974
Provider Enumeration Date:
11/12/2014