Provider First Line Business Practice Location Address:
4424 E FLAMINGO
Provider Second Line Business Practice Location Address:
AVE STE 300
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-302-0200
Provider Business Practice Location Address Fax Number:
208-302-0055
Provider Enumeration Date:
05/19/2006