Provider First Line Business Practice Location Address:
223 16TH AVE N
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:
83687-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-7869
Provider Business Practice Location Address Fax Number:
208-466-5359
Provider Enumeration Date:
11/04/2011