Provider First Line Business Practice Location Address:
901 12TH 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:
83651-4658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-9251
Provider Business Practice Location Address Fax Number:
208-463-1714
Provider Enumeration Date:
07/15/2019