Provider First Line Business Practice Location Address:
460 W ORCHARD AVE APT E301
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:
83651-1993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-434-2342
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2025