Provider First Line Business Practice Location Address:
2060 S WOODRUFF AVE
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:
83404-6396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-7246
Provider Business Practice Location Address Fax Number:
208-523-7247
Provider Enumeration Date:
08/17/2006