Provider First Line Business Practice Location Address:
1015 12TH AVE S
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:
83651-4660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-4357
Provider Business Practice Location Address Fax Number:
208-467-4395
Provider Enumeration Date:
05/29/2024