Provider First Line Business Practice Location Address:
1224 S 19TH 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:
83686-7388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-558-6680
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2024