Provider First Line Business Practice Location Address:
1018 W SANETTA ST STE 4
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:
83651-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-614-4122
Provider Business Practice Location Address Fax Number:
208-955-2025
Provider Enumeration Date:
09/28/2026