Provider First Line Business Practice Location Address:
130 S MIDLAND BLVD
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:
83686-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-318-6214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2019