Provider First Line Business Practice Location Address:
380 N CAPITAL AVE
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:
83402-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-881-5059
Provider Business Practice Location Address Fax Number:
888-898-0407
Provider Enumeration Date:
12/16/2013