Provider First Line Business Practice Location Address:
660 S WOODRUFF 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:
83401-5299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1558
Provider Business Practice Location Address Fax Number:
208-529-4788
Provider Enumeration Date:
06/25/2008