Provider First Line Business Practice Location Address:
1625 S MERIDIAN RD
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:
83642-9355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-319-0600
Provider Business Practice Location Address Fax Number:
208-319-0606
Provider Enumeration Date:
08/26/2024