Provider First Line Business Practice Location Address:
2705 E 17TH ST STE S5
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:
208-932-1670
Provider Business Practice Location Address Fax Number:
208-523-7678
Provider Enumeration Date:
05/29/2019