Provider First Line Business Practice Location Address:
923 16TH AVE S
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:
83651-4731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-965-8788
Provider Business Practice Location Address Fax Number:
208-965-2789
Provider Enumeration Date:
08/10/2006