Provider First Line Business Practice Location Address:
5483 N BLACK SAND AVE
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:
83646-5662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-251-8920
Provider Business Practice Location Address Fax Number:
208-264-9569
Provider Enumeration Date:
10/02/2025