Provider First Line Business Practice Location Address:
820 17TH 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:
83651-4740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-4261
Provider Business Practice Location Address Fax Number:
208-466-6288
Provider Enumeration Date:
09/03/2014