Provider First Line Business Practice Location Address:
3456 E 17TH ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-6757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-0030
Provider Business Practice Location Address Fax Number:
208-523-3828
Provider Enumeration Date:
11/16/2005