Provider First Line Business Practice Location Address:
2450 E GALA ST STE 100
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:
83642-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-994-8180
Provider Business Practice Location Address Fax Number:
208-908-4542
Provider Enumeration Date:
01/08/2013