Provider First Line Business Practice Location Address:
3475 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:
83406-6781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-227-5083
Provider Business Practice Location Address Fax Number:
208-227-5087
Provider Enumeration Date:
09/16/2011