Provider First Line Business Practice Location Address:
2874 N MULE DEER WAY
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:
83646-7812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-407-2831
Provider Business Practice Location Address Fax Number:
208-887-2278
Provider Enumeration Date:
04/27/2009