Provider First Line Business Practice Location Address:
25 14TH AVE 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:
83651-4394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-465-1890
Provider Business Practice Location Address Fax Number:
208-467-9131
Provider Enumeration Date:
02/24/2007