Provider First Line Business Practice Location Address:
10716 LAKE SHORE DR
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:
83686-9326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-412-0203
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2012