Provider First Line Business Practice Location Address:
1201 W FLAMINGO 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:
83651-1829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-922-8680
Provider Business Practice Location Address Fax Number:
208-936-3121
Provider Enumeration Date:
01/18/2019