Provider First Line Business Practice Location Address:
623 7TH AVE 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:
83651-4171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-954-9980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2025