Provider First Line Business Practice Location Address:
101 11TH AVE S STE 105
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:
83651-3945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-690-4610
Provider Business Practice Location Address Fax Number:
208-962-1004
Provider Enumeration Date:
03/23/2026