Provider First Line Business Practice Location Address:
4286 E AMITY AVE STE 104
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:
83687-8176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-442-1052
Provider Business Practice Location Address Fax Number:
208-461-4685
Provider Enumeration Date:
10/03/2006