Provider First Line Business Practice Location Address:
1301 N 59TH 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:
83687-8515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-704-0907
Provider Business Practice Location Address Fax Number:
208-254-5589
Provider Enumeration Date:
06/22/2024