Provider First Line Business Practice Location Address:
1740 E 17TH ST
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:
83404-6375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-346-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2012