Provider First Line Business Practice Location Address:
3385 POTOMAC 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:
83404-4978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-7159
Provider Business Practice Location Address Fax Number:
208-522-2767
Provider Enumeration Date:
04/15/2009