Provider First Line Business Practice Location Address:
3109 S MERIDIAN RD
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:
83642-7088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-0660
Provider Business Practice Location Address Fax Number:
208-567-5973
Provider Enumeration Date:
01/12/2007