Provider First Line Business Practice Location Address:
222 N SUGAR ST
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:
83687-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-9313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2024