Provider First Line Business Practice Location Address:
414 SHOUP AVE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-6373
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2008