Provider First Line Business Practice Location Address:
3767 PROFESSIONAL WAY
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:
83402-7315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-907-4682
Provider Business Practice Location Address Fax Number:
208-785-9883
Provider Enumeration Date:
07/21/2025