Provider First Line Business Practice Location Address:
4400 E FLAMINGO AVE STE 130
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-205-0350
Provider Business Practice Location Address Fax Number:
208-205-0356
Provider Enumeration Date:
07/10/2013