Provider First Line Business Practice Location Address:
1115 12TH AVE
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:
83686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-498-1080
Provider Business Practice Location Address Fax Number:
208-498-1081
Provider Enumeration Date:
10/02/2017