Provider First Line Business Practice Location Address:
1224 1ST ST S STE 300
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:
83651-3963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-615-5912
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2025