Provider First Line Business Practice Location Address:
1430 W USTICK RD 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:
83646-7734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-286-8670
Provider Business Practice Location Address Fax Number:
866-807-6068
Provider Enumeration Date:
08/31/2023