Provider First Line Business Practice Location Address:
16174 N HIGH DESERT 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:
83687-5510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-9778
Provider Business Practice Location Address Fax Number:
208-466-9385
Provider Enumeration Date:
07/13/2009