Provider First Line Business Practice Location Address:
1004 13TH AVE S
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:
83651-4621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-461-4227
Provider Business Practice Location Address Fax Number:
208-461-3411
Provider Enumeration Date:
01/07/2008