Provider First Line Business Practice Location Address:
1320 S AMMON RD
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:
83406-5810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-360-6770
Provider Business Practice Location Address Fax Number:
208-542-6353
Provider Enumeration Date:
06/15/2023