Provider First Line Business Practice Location Address:
323 W. PINE AVE.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-5858
Provider Business Practice Location Address Fax Number:
208-884-1508
Provider Enumeration Date:
11/22/2016