Provider First Line Business Practice Location Address:
5957 W. 33RD SOUTH
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:
83402-5682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-313-1994
Provider Business Practice Location Address Fax Number:
208-552-3341
Provider Enumeration Date:
03/27/2009