Provider First Line Business Practice Location Address:
17 12TH AVE S SUITE 207
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:
83651-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-649-4962
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2011