Provider First Line Business Practice Location Address:
690 S INDUSTRY WAY
Provider Second Line Business Practice Location Address:
SUITE 45
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:
208-922-2207
Provider Business Practice Location Address Fax Number:
208-922-4168
Provider Enumeration Date:
10/02/2006