Provider First Line Business Practice Location Address:
836 W LOCUST LN
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:
83686-8231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-8315
Provider Business Practice Location Address Fax Number:
208-468-0566
Provider Enumeration Date:
05/11/2008