Provider First Line Business Practice Location Address:
573 S LOCUST GROVE RD
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:
83642-4739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-322-5055
Provider Business Practice Location Address Fax Number:
208-322-8033
Provider Enumeration Date:
07/31/2007