Provider First Line Business Practice Location Address:
2840 S MERIDIAN 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:
83642-7960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-593-6393
Provider Business Practice Location Address Fax Number:
208-593-6402
Provider Enumeration Date:
02/13/2024