Provider First Line Business Practice Location Address:
16 12TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651-3936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-489-6866
Provider Business Practice Location Address Fax Number:
208-475-6025
Provider Enumeration Date:
01/09/2013