Provider First Line Business Practice Location Address:
586 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-3963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2920
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007