Provider First Line Business Practice Location Address:
10022 JORDAN LEE ST
Provider Second Line Business Practice Location Address:
STE 101
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:
208-614-0067
Provider Business Practice Location Address Fax Number:
208-615-2555
Provider Enumeration Date:
05/24/2005