Provider First Line Business Practice Location Address:
3277 E. LOUISE DR., STE. 200
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:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-468-5910
Provider Business Practice Location Address Fax Number:
208-884-2979
Provider Enumeration Date:
05/03/2007