Provider First Line Business Practice Location Address:
3200 CHANNING WAY STE A101
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:
83404-7561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-1166
Provider Business Practice Location Address Fax Number:
208-552-0470
Provider Enumeration Date:
11/15/2012