Provider First Line Business Practice Location Address:
1611 12TH AVE RD STE B
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:
83686-6182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-1107
Provider Business Practice Location Address Fax Number:
208-461-2633
Provider Enumeration Date:
11/08/2017