Provider First Line Business Practice Location Address:
811 12TH AVE S
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651-4656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-571-4018
Provider Business Practice Location Address Fax Number:
208-247-4312
Provider Enumeration Date:
01/25/2012