Provider First Line Business Practice Location Address:
924 3RD ST S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651-3817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-461-6523
Provider Business Practice Location Address Fax Number:
208-461-9130
Provider Enumeration Date:
12/11/2006