Provider First Line Business Practice Location Address:
15592 N LEXHAM AVE
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:
83651-4329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-353-1934
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2026