Provider First Line Business Practice Location Address:
2053 E FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-0977
Provider Business Practice Location Address Fax Number:
208-895-0978
Provider Enumeration Date:
02/01/2007