Provider First Line Business Practice Location Address:
123 N YALE ST
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:
83651-2340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-585-3375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2023