Provider First Line Business Practice Location Address:
112 9TH AVE S STE B10
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:
83651-3825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-471-4975
Provider Business Practice Location Address Fax Number:
208-318-5017
Provider Enumeration Date:
09/17/2018