Provider First Line Business Practice Location Address:
255 B ST STE 308
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:
83402-3517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-244-0040
Provider Business Practice Location Address Fax Number:
208-244-0040
Provider Enumeration Date:
05/13/2025