Provider First Line Business Practice Location Address:
7112 E CANTERBURY LN
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:
83687-9432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-743-3179
Provider Business Practice Location Address Fax Number:
800-367-6163
Provider Enumeration Date:
06/12/2007