Provider First Line Business Practice Location Address:
2214 E. ELM GROVE DR.
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:
83686-7006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-573-1273
Provider Business Practice Location Address Fax Number:
208-437-7488
Provider Enumeration Date:
06/22/2018