Provider First Line Business Practice Location Address:
1009 W HEMINGWAY BLVD
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:
83651-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-453-8915
Provider Business Practice Location Address Fax Number:
208-453-8937
Provider Enumeration Date:
01/19/2011