Provider First Line Business Practice Location Address:
1105 2ND 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:
83651-3911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-250-0836
Provider Business Practice Location Address Fax Number:
888-972-6280
Provider Enumeration Date:
05/06/2014