Provider First Line Business Practice Location Address:
619 S CANYON ST
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:
83686-6634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-468-4635
Provider Business Practice Location Address Fax Number:
208-465-2715
Provider Enumeration Date:
01/22/2007