Provider First Line Business Practice Location Address:
4806 SOUTHSIDE BLVD
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:
83686-8919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-4286
Provider Business Practice Location Address Fax Number:
208-442-1345
Provider Enumeration Date:
02/19/2007