Provider First Line Business Practice Location Address:
3709 N LOCUST GROVE RD 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:
83646-5924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-577-7634
Provider Business Practice Location Address Fax Number:
208-378-8389
Provider Enumeration Date:
08/29/2008