Provider First Line Business Practice Location Address:
217 WEST GEORGIA AVE
Provider Second Line Business Practice Location Address:
SUITE 120, ROOM P
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-800-6030
Provider Business Practice Location Address Fax Number:
208-629-2871
Provider Enumeration Date:
04/12/2023