Provider First Line Business Practice Location Address:
3101 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:
83406-6717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-4824
Provider Business Practice Location Address Fax Number:
208-523-6830
Provider Enumeration Date:
02/09/2010