Provider First Line Business Practice Location Address:
1210 E 17TH 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:
83404-6147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-0006
Provider Business Practice Location Address Fax Number:
208-535-0007
Provider Enumeration Date:
06/16/2009