Provider First Line Business Practice Location Address:
207 16TH AVE NORTH
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:
83653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-7654
Provider Business Practice Location Address Fax Number:
208-467-7684
Provider Enumeration Date:
06/29/2006