Provider First Line Business Practice Location Address:
280 E CORPORATE DR
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-287-2032
Provider Business Practice Location Address Fax Number:
208-287-2033
Provider Enumeration Date:
02/21/2011