Provider First Line Business Practice Location Address:
430 W. IOWA AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-2856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-442-1123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007