Provider First Line Business Practice Location Address:
122 WEST GEORGIA AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-6910
Provider Business Practice Location Address Fax Number:
208-461-8972
Provider Enumeration Date:
05/10/2007