Provider First Line Business Practice Location Address:
3160 E 17TH ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-6717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-7844
Provider Business Practice Location Address Fax Number:
208-528-9473
Provider Enumeration Date:
04/02/2007