Provider First Line Business Practice Location Address:
106 HOLLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-465-6717
Provider Business Practice Location Address Fax Number:
208-465-6392
Provider Enumeration Date:
03/18/2009