Provider First Line Business Practice Location Address:
3645 E OVERLAND RD
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:
83642-6751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-593-5252
Provider Business Practice Location Address Fax Number:
208-593-5251
Provider Enumeration Date:
06/27/2018