Provider First Line Business Practice Location Address:
3040 E 17TH ST
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:
83406-6760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-557-0200
Provider Business Practice Location Address Fax Number:
208-542-5080
Provider Enumeration Date:
01/17/2015