Provider First Line Business Practice Location Address: 
1948 S EAGLE ROAD
    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: 
208-322-7900
    Provider Business Practice Location Address Fax Number: 
208-322-6405
    Provider Enumeration Date: 
03/15/2018