Provider First Line Business Practice Location Address:
1224 1ST ST S
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-4889
Provider Business Practice Location Address Fax Number:
208-467-4499
Provider Enumeration Date:
02/17/2012