Provider First Line Business Practice Location Address:
2355 CORONADO 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:
83404-7407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-0303
Provider Business Practice Location Address Fax Number:
208-523-9815
Provider Enumeration Date:
10/20/2006