Provider First Line Business Practice Location Address:
1217 3RD ST S STE 103
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:
83651-1003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-565-8213
Provider Business Practice Location Address Fax Number:
208-845-6059
Provider Enumeration Date:
02/02/2021