Provider First Line Business Practice Location Address:
1582 ELK CREEK DRIVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-5414
Provider Business Practice Location Address Fax Number:
208-552-2708
Provider Enumeration Date:
07/31/2006