Provider First Line Business Practice Location Address:
3160 E 17TH ST STE 164
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:
83406-6784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-1795
Provider Business Practice Location Address Fax Number:
208-529-1838
Provider Enumeration Date:
10/27/2015