Provider First Line Business Practice Location Address:
4943 N 29 E
Provider Second Line Business Practice Location Address:
SUITE B
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-257-5487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2026