Provider First Line Business Practice Location Address:
16150 N HIGH DESERT ST STE 213
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:
83687-5742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-495-6055
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2026