Provider First Line Business Practice Location Address:
440 W PENNWOOD ST STE 200
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:
83642-8602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-9148
Provider Business Practice Location Address Fax Number:
208-884-2164
Provider Enumeration Date:
08/12/2010