Provider First Line Business Practice Location Address: 
2220 E 25TH 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: 
83404-7542
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-523-1122
    Provider Business Practice Location Address Fax Number: 
208-523-2582
    Provider Enumeration Date: 
07/19/2006