Provider First Line Business Practice Location Address:
112 9TH AVE
Provider Second Line Business Practice Location Address:
B7
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-482-8012
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2019