Provider First Line Business Practice Location Address:
179 SW 5TH AVENUE
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:
208-367-8282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2015