Provider First Line Business Practice Location Address:
5709 E EFFRA ST
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:
83687-7611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-437-0499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2023