Provider First Line Business Practice Location Address:
2950 E MAGIC VIEW DR.
Provider Second Line Business Practice Location Address:
SUITE 192
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:
208-888-7900
Provider Business Practice Location Address Fax Number:
208-888-7591
Provider Enumeration Date:
11/24/2006