Provider First Line Business Practice Location Address:
2365 E GALA ST STE 1
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:
208-515-2654
Provider Business Practice Location Address Fax Number:
877-587-3112
Provider Enumeration Date:
08/03/2006