Provider First Line Business Practice Location Address:
1601 E 17TH 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:
83404-6313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-2090
Provider Business Practice Location Address Fax Number:
208-525-2662
Provider Enumeration Date:
01/30/2008