Provider First Line Business Practice Location Address:
222 W IOWA AVE STE B
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-3432
Provider Business Practice Location Address Fax Number:
208-467-4147
Provider Enumeration Date:
10/02/2006