Provider First Line Business Practice Location Address:
52 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:
83651-2347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
986-942-2182
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2026