Provider First Line Business Practice Location Address:
1713 E IOWA 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:
83686-5641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-440-8967
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2014