Provider First Line Business Practice Location Address:
2302 S WILDRYE WAY
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:
83686-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-899-1544
Provider Business Practice Location Address Fax Number:
208-544-4030
Provider Enumeration Date:
06/08/2026