Provider First Line Business Practice Location Address:
3715 E OVERLAND RD
Provider Second Line Business Practice Location Address:
UNIT 105
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-0055
Provider Business Practice Location Address Fax Number:
208-888-5062
Provider Enumeration Date:
01/21/2016