Provider First Line Business Practice Location Address:
1906 W GROUSE ST
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:
83651-8340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-442-0325
Provider Business Practice Location Address Fax Number:
208-442-5271
Provider Enumeration Date:
11/26/2011