Provider First Line Business Practice Location Address:
1616 E PLAZA LOOP
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:
83687-4931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-287-1733
Provider Business Practice Location Address Fax Number:
208-287-1734
Provider Enumeration Date:
11/10/2020