Provider First Line Business Practice Location Address:
1512 12TH AVE RD
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:
83686-6008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-5431
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007