Provider First Line Business Practice Location Address:
6019 LEMHI 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:
83404-8064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-452-4755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2022