Provider First Line Business Practice Location Address:
1480 MIDWAY AVE
Provider Second Line Business Practice Location Address:
UNIT 7
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-4587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1980
Provider Business Practice Location Address Fax Number:
208-529-4013
Provider Enumeration Date:
01/26/2016