Provider First Line Business Practice Location Address:
110 12TH AVE S STE 201
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:
83651-3934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-402-8769
Provider Business Practice Location Address Fax Number:
208-266-5610
Provider Enumeration Date:
08/07/2025