Provider First Line Business Practice Location Address:
1024 E AMITY AVE
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:
83686-5502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-284-6243
Provider Business Practice Location Address Fax Number:
208-475-7224
Provider Enumeration Date:
10/22/2020