Provider First Line Business Practice Location Address:
1130 E FAIRVIEW 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:
83642-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-6729
Provider Business Practice Location Address Fax Number:
208-855-5921
Provider Enumeration Date:
10/23/2019