Provider First Line Business Practice Location Address:
1558 MIDWAY AVE.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-709-4660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2018