Provider First Line Business Practice Location Address: 
119 S VALLEY DR STE E
    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: 
83686-2985
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-468-9191
    Provider Business Practice Location Address Fax Number: 
208-466-7479
    Provider Enumeration Date: 
07/24/2007