Provider First Line Business Practice Location Address:
232 2ND ST 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:
83651-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-453-8915
Provider Business Practice Location Address Fax Number:
208-453-8937
Provider Enumeration Date:
08/17/2011