Provider First Line Business Practice Location Address:
4 OGDEN AVE
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:
83651-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-505-4314
Provider Business Practice Location Address Fax Number:
208-475-4460
Provider Enumeration Date:
09/18/2013