Provider First Line Business Practice Location Address:
3140 W MILANO DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-7290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-4775
Provider Business Practice Location Address Fax Number:
208-888-1344
Provider Enumeration Date:
09/02/2005