Provider First Line Business Practice Location Address:
3155 CHANNING WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-4800
Provider Business Practice Location Address Fax Number:
208-535-4807
Provider Enumeration Date:
11/08/2006