Provider First Line Business Practice Location Address:
203 LAKE LOWELL AVE
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:
83686-6697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-498-0551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2025