Provider First Line Business Practice Location Address:
119 S VALLEY DR STE E
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:
83686-2985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-468-9191
Provider Business Practice Location Address Fax Number:
208-466-7479
Provider Enumeration Date:
07/24/2007