Provider First Line Business Practice Location Address:
3135 E 17TH ST STE C
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:
83406-6779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4211
Provider Business Practice Location Address Fax Number:
208-524-3695
Provider Enumeration Date:
12/18/2006