Provider First Line Business Practice Location Address:
1510 E WATERTOWER ST STE 100
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:
83642-7993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-724-1410
Provider Business Practice Location Address Fax Number:
208-899-8901
Provider Enumeration Date:
03/22/2019