Provider First Line Business Practice Location Address:
84 BOMBER RD
Provider Second Line Business Practice Location Address:
726TH AIR CONTROL SQUADRON
Provider Business Practice Location Address City Name:
MOUNTAIN HOME A F B
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83648-5272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-828-3604
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2009