Provider First Line Business Practice Location Address:
260 S TEN MILE RD
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:
83642-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-809-2872
Provider Business Practice Location Address Fax Number:
208-809-2873
Provider Enumeration Date:
03/02/2018