Provider First Line Business Practice Location Address:
2707 GARRITY BLVD STE 5
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:
83687-3679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-7443
Provider Business Practice Location Address Fax Number:
208-466-5058
Provider Enumeration Date:
05/29/2007