Provider First Line Business Practice Location Address:
715 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:
83651-4254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-3592
Provider Business Practice Location Address Fax Number:
208-463-1392
Provider Enumeration Date:
06/20/2011