Provider First Line Business Practice Location Address:
2539 CHANNING WAY
Provider Second Line Business Practice Location Address:
SUITE # 260
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-589-1013
Provider Business Practice Location Address Fax Number:
208-523-5991
Provider Enumeration Date:
08/20/2006