Provider First Line Business Practice Location Address:
37 W ARCHERFIELD ST STE 100
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:
83646-6587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-9958
Provider Business Practice Location Address Fax Number:
208-298-0646
Provider Enumeration Date:
04/25/2008