Provider First Line Business Practice Location Address:
210 W GEORGIA AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-5688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-468-5915
Provider Business Practice Location Address Fax Number:
208-463-3044
Provider Enumeration Date:
06/27/2006