Provider First Line Business Practice Location Address:
2375 E. SUNNYSIDE RD, STE J
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:
83404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-7060
Provider Business Practice Location Address Fax Number:
208-522-2202
Provider Enumeration Date:
05/23/2006