Provider First Line Business Practice Location Address:
1550 N CRESTMONT DRIVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-629-2023
Provider Business Practice Location Address Fax Number:
208-759-5840
Provider Enumeration Date:
04/25/2017