Provider First Line Business Practice Location Address:
211 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-4369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-1112
Provider Business Practice Location Address Fax Number:
208-524-1113
Provider Enumeration Date:
10/28/2010