Provider First Line Business Practice Location Address:
1512 12TH AVE RD
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:
83686-6008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-263-1223
Provider Business Practice Location Address Fax Number:
208-463-5081
Provider Enumeration Date:
06/23/2008