Provider First Line Business Practice Location Address:
422 11TH AVE S
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:
83651-4233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-442-8200
Provider Business Practice Location Address Fax Number:
208-442-1418
Provider Enumeration Date:
09/11/2013