Provider First Line Business Practice Location Address:
2300 E 17TH ST
Provider Second Line Business Practice Location Address:
SUITE 1157
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-3355
Provider Business Practice Location Address Fax Number:
208-552-6120
Provider Enumeration Date:
07/02/2008