Provider First Line Business Practice Location Address:
2860 CHANNING WAY
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-0575
Provider Business Practice Location Address Fax Number:
208-528-0223
Provider Enumeration Date:
02/19/2009