Provider First Line Business Practice Location Address:
2211 3RD ST 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:
83651-5418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-488-2339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2024