Provider First Line Business Practice Location Address:
520 S MERIDIAN RD STE 50
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:
83642-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-989-4110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2008