Provider First Line Business Practice Location Address:
1203 10TH ST S
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:
83651-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-6567
Provider Business Practice Location Address Fax Number:
208-467-5428
Provider Enumeration Date:
07/30/2007