Provider First Line Business Practice Location Address:
3200 CHANNING WAY
Provider Second Line Business Practice Location Address:
A-105
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-9530
Provider Business Practice Location Address Fax Number:
208-522-6262
Provider Enumeration Date:
06/15/2006