Provider First Line Business Practice Location Address:
1307 W ELMORE 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:
83651-7656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-697-6664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2025