Provider First Line Business Practice Location Address:
1216 GARRITY 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:
83687-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-954-8218
Provider Business Practice Location Address Fax Number:
208-368-0863
Provider Enumeration Date:
12/03/2021