Provider First Line Business Practice Location Address:
97 N 29TH ST
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:
83687-3669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-603-4930
Provider Business Practice Location Address Fax Number:
208-205-8062
Provider Enumeration Date:
07/10/2018