Provider First Line Business Practice Location Address:
124 MCCLURE AVE
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:
83651-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-369-6063
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2014