Provider First Line Business Practice Location Address:
1214 12TH AVE S
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:
83651-4665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-484-1917
Provider Business Practice Location Address Fax Number:
208-468-3138
Provider Enumeration Date:
07/20/2007