Provider First Line Business Practice Location Address:
2525 N STOKESBERRY PL STE B
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:
83646-1144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-955-6610
Provider Business Practice Location Address Fax Number:
208-955-6612
Provider Enumeration Date:
03/19/2009