Provider First Line Business Practice Location Address:
2001 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4511
Provider Business Practice Location Address Fax Number:
208-524-4540
Provider Enumeration Date:
09/09/2005