Provider First Line Business Practice Location Address:
811 12TH STREET
Provider Second Line Business Practice Location Address:
STE. 2
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-571-4018
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2012