Provider First Line Business Practice Location Address:
324 S MERIDIAN RD
Provider Second Line Business Practice Location Address:
SUITE10
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-5497
Provider Business Practice Location Address Fax Number:
208-887-6498
Provider Enumeration Date:
08/30/2005