Provider First Line Business Practice Location Address:
1582 N HOLMES AVENUE
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:
83401-2032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-8832
Provider Business Practice Location Address Fax Number:
208-535-7595
Provider Enumeration Date:
06/26/2006