Provider First Line Business Practice Location Address:
2090 S EAGLE 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:
83642-6707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-992-3500
Provider Business Practice Location Address Fax Number:
208-618-3074
Provider Enumeration Date:
11/30/2022