Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE RD
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:
83404-8280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-0610
Provider Business Practice Location Address Fax Number:
208-557-0171
Provider Enumeration Date:
09/26/2006