Provider First Line Business Practice Location Address:
54 N LUKE LOOP
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:
83651-5185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-697-8900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2024