Provider First Line Business Practice Location Address:
4301 GARRITY BLVD STE 203
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:
83687-9221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-323-2727
Provider Business Practice Location Address Fax Number:
208-323-1615
Provider Enumeration Date:
11/14/2023