Provider First Line Business Practice Location Address:
2705 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:
83406-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-346-7500
Provider Business Practice Location Address Fax Number:
208-346-7501
Provider Enumeration Date:
07/23/2018