Provider First Line Business Practice Location Address:
1200 N MAIN ST
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:
83642-8799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-985-5126
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2011