Provider First Line Business Practice Location Address:
5700 E FRANKLIN RD
Provider Second Line Business Practice Location Address:
SUITE 220E
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687-8497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-936-1097
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2009