Provider First Line Business Practice Location Address:
1558 N CRESTMONT DR STE C
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:
83642-2194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-572-2100
Provider Business Practice Location Address Fax Number:
208-505-1742
Provider Enumeration Date:
01/20/2015