Provider First Line Business Practice Location Address:
2330 DESOTO 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:
83404-7570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1100
Provider Business Practice Location Address Fax Number:
208-523-1317
Provider Enumeration Date:
01/22/2007