Provider First Line Business Practice Location Address:
980 12TH 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:
83404-5051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-526-1596
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2023