Provider First Line Business Practice Location Address:
847-1 PARKCENTRE WAY
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:
83651-1792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-4659
Provider Business Practice Location Address Fax Number:
208-342-8211
Provider Enumeration Date:
05/20/2009