Provider First Line Business Practice Location Address:
5826 E FRANKLIN 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:
83687-5020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-318-1619
Provider Business Practice Location Address Fax Number:
208-318-1612
Provider Enumeration Date:
11/19/2019