Provider First Line Business Practice Location Address:
1020 LAND BANK 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:
83402-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-650-7359
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2025