Provider First Line Business Practice Location Address:
3023 S HAPPY VALLEY 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:
83686-8698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-301-7592
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2025