Provider First Line Business Practice Location Address:
847 PARK CENTRE WAY
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-2673
Provider Business Practice Location Address Fax Number:
208-467-4150
Provider Enumeration Date:
04/11/2013