Provider First Line Business Practice Location Address:
508 E FLORIDA 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:
83686-5823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-0118
Provider Business Practice Location Address Fax Number:
208-463-1507
Provider Enumeration Date:
08/19/2013