Provider First Line Business Practice Location Address:
1980 1ST 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:
83401-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2007