Provider First Line Business Practice Location Address:
2025 12TH AVE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-461-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2007