Provider First Line Business Practice Location Address:
543 3RD 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:
83401-3909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-6925
Provider Business Practice Location Address Fax Number:
208-522-6934
Provider Enumeration Date:
09/24/2013