Provider First Line Business Practice Location Address:
172 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:
83651-3708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-489-5950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2011