Provider First Line Business Practice Location Address:
2498 N STOKESBERRY PL STE 150
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:
83646-5150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-957-5450
Provider Business Practice Location Address Fax Number:
208-957-5292
Provider Enumeration Date:
11/16/2007