Provider First Line Business Practice Location Address:
104 9TH AVE S STE B3
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:
83651-3852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-495-4263
Provider Business Practice Location Address Fax Number:
208-936-3836
Provider Enumeration Date:
11/30/2010