Provider First Line Business Practice Location Address:
1601 12TH AVE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-0200
Provider Business Practice Location Address Fax Number:
208-621-3140
Provider Enumeration Date:
01/29/2016