Provider First Line Business Practice Location Address:
290 W GEORGIA AVE
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:
83686-2835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-3298
Provider Business Practice Location Address Fax Number:
208-463-3044
Provider Enumeration Date:
02/14/2007