Provider First Line Business Practice Location Address:
212 5TH AVE S
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:
83651-3740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-312-0559
Provider Business Practice Location Address Fax Number:
208-907-0975
Provider Enumeration Date:
03/07/2018