Provider First Line Business Practice Location Address:
2585 CHANNING WAY
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:
83404-7516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-0200
Provider Business Practice Location Address Fax Number:
208-523-6051
Provider Enumeration Date:
11/30/2006