Provider First Line Business Practice Location Address:
1010 W TETON AVE
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:
83686-9778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-312-7148
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2016