Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE ROAD
Provider Second Line Business Practice Location Address:
SUITE G
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-8232
Provider Business Practice Location Address Fax Number:
866-499-9979
Provider Enumeration Date:
02/05/2007