Provider First Line Business Practice Location Address:
100 S ADKINS WAY
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-6232
Provider Business Practice Location Address Fax Number:
208-888-5201
Provider Enumeration Date:
06/24/2015