Provider First Line Business Practice Location Address:
228 HOLLY 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:
83686-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-5759
Provider Business Practice Location Address Fax Number:
208-467-4510
Provider Enumeration Date:
06/16/2009