Provider First Line Business Practice Location Address:
2442 E. 25TH ST.
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:
83404-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-4909
Provider Business Practice Location Address Fax Number:
940-612-3636
Provider Enumeration Date:
08/16/2005