Provider First Line Business Practice Location Address:
1536 MIDWAY AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-8305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-403-0135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2013