Provider First Line Business Practice Location Address:
1640 W CHERRY LN STE 130
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:
83642-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-895-8595
Provider Business Practice Location Address Fax Number:
208-884-1835
Provider Enumeration Date:
08/01/2006