Provider First Line Business Practice Location Address:
1406 N MAIN ST STE 111
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:
83642-1798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-602-8211
Provider Business Practice Location Address Fax Number:
208-906-0852
Provider Enumeration Date:
02/05/2016