Provider First Line Business Practice Location Address:
1204 W HUDSON 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:
83651-2131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-880-4678
Provider Business Practice Location Address Fax Number:
208-442-7387
Provider Enumeration Date:
02/12/2013