Provider First Line Business Practice Location Address:
623 S UNIVERSITY 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:
83686-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-910-7401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2020