Provider First Line Business Practice Location Address:
1312 S EDGEWATER CIR
Provider Second Line Business Practice Location Address:
SUITE #4
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-440-0107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2013