Provider First Line Business Practice Location Address:
315 7TH 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:
83651-3848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-860-0397
Provider Business Practice Location Address Fax Number:
208-475-4460
Provider Enumeration Date:
02/02/2017