Provider First Line Business Practice Location Address:
1305 3RD ST S
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-936-1097
Provider Business Practice Location Address Fax Number:
208-475-5710
Provider Enumeration Date:
01/20/2011