Provider First Line Business Practice Location Address:
815 11TH AVE S
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:
83651-4509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-442-2978
Provider Business Practice Location Address Fax Number:
208-442-7901
Provider Enumeration Date:
07/03/2014