Provider First Line Business Practice Location Address:
215 E HAWAII 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:
83686-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-514-2529
Provider Business Practice Location Address Fax Number:
208-375-2217
Provider Enumeration Date:
03/24/2016