Provider First Line Business Practice Location Address:
1900 N LAKES PL
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-7242
Provider Business Practice Location Address Fax Number:
208-888-7263
Provider Enumeration Date:
11/05/2010