Provider First Line Business Practice Location Address:
3360 WASHINGTON PKWY STE 1
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:
83404-8333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3416
Provider Business Practice Location Address Fax Number:
208-524-3138
Provider Enumeration Date:
03/26/2011