Provider First Line Business Practice Location Address:
2976 S MERIDIAN RD STE 150
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:
83642-8532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-515-7575
Provider Business Practice Location Address Fax Number:
208-515-7578
Provider Enumeration Date:
08/29/2024