Provider First Line Business Practice Location Address:
660 E FRANKLIN RD STE 140
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:
83642-2914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-992-2672
Provider Business Practice Location Address Fax Number:
208-992-2673
Provider Enumeration Date:
07/12/2021