Provider First Line Business Practice Location Address:
408 22ND AVE S
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:
83651-5424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-8267
Provider Business Practice Location Address Fax Number:
208-466-5226
Provider Enumeration Date:
04/22/2013