Provider First Line Business Practice Location Address:
1615 12TH AVE RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-7713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-4406
Provider Business Practice Location Address Fax Number:
208-467-4450
Provider Enumeration Date:
03/14/2006