Provider First Line Business Practice Location Address:
1224 1ST STREET NORTH
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-2314
Provider Business Practice Location Address Fax Number:
208-463-4390
Provider Enumeration Date:
03/24/2006