Provider First Line Business Practice Location Address:
78 SW 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-0692
Provider Business Practice Location Address Fax Number:
208-288-0467
Provider Enumeration Date:
04/12/2007