Provider First Line Business Practice Location Address:
140 N CORNER 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:
83402-4032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-0785
Provider Business Practice Location Address Fax Number:
208-523-0785
Provider Enumeration Date:
05/15/2008