Provider First Line Business Practice Location Address:
5298 S MEMORY AVE
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:
83642-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-314-2345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2026