Provider First Line Business Practice Location Address:
304 12TH AVE RD
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:
83686-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-800-1948
Provider Business Practice Location Address Fax Number:
208-475-6270
Provider Enumeration Date:
03/14/2025