Provider First Line Business Practice Location Address:
269 E 5TH ST
Provider Second Line Business Practice Location Address:
STE 101/103
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-1415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-750-7828
Provider Business Practice Location Address Fax Number:
866-750-7828
Provider Enumeration Date:
11/06/2008