Provider First Line Business Practice Location Address:
1512 4TH ST N
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:
83687-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-409-1259
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2026