Provider First Line Business Practice Location Address:
2960 E. ST. LUKE'S ST.
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-9005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-378-4264
Provider Business Practice Location Address Fax Number:
208-957-6891
Provider Enumeration Date:
03/26/2019