Provider First Line Business Practice Location Address:
3630 E LOUISE DRIVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-9515
Provider Business Practice Location Address Fax Number:
208-377-9517
Provider Enumeration Date:
06/29/2006