Provider First Line Business Practice Location Address:
3770 E AMITY AVE UNIT 106
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:
83687-1194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-750-8235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2025