Provider First Line Business Practice Location Address:
3904 E FLAMINGO AVENUE
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687-3102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-089-1888
Provider Business Practice Location Address Fax Number:
208-839-2301
Provider Enumeration Date:
01/25/2012