Provider First Line Business Practice Location Address:
303 12TH AVE 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:
83686-5014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-465-5865
Provider Business Practice Location Address Fax Number:
208-361-4266
Provider Enumeration Date:
01/09/2012