Provider First Line Business Practice Location Address:
360 E MONTVUE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-6318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-2900
Provider Business Practice Location Address Fax Number:
208-898-9788
Provider Enumeration Date:
06/19/2006