Provider First Line Business Practice Location Address:
1063 E LEWIS LN
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:
83686-8843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-7952
Provider Business Practice Location Address Fax Number:
208-466-7961
Provider Enumeration Date:
01/05/2009