Provider First Line Business Practice Location Address:
1512 12TH AVE RD
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:
83653-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-461-2883
Provider Business Practice Location Address Fax Number:
208-461-2953
Provider Enumeration Date:
10/11/2005