Provider First Line Business Practice Location Address:
1550 N CRESTMONT DR STE G
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:
83642-2177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-0100
Provider Business Practice Location Address Fax Number:
208-884-4844
Provider Enumeration Date:
10/29/2008