Provider First Line Business Practice Location Address:
1510 12TH AVE RD STE 200
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:
83686-6946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-302-6800
Provider Business Practice Location Address Fax Number:
208-302-6855
Provider Enumeration Date:
03/29/2022