Provider First Line Business Practice Location Address:
1975 MARTHA AVE STE B
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:
83404-7580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-932-4475
Provider Business Practice Location Address Fax Number:
208-330-0664
Provider Enumeration Date:
09/20/2006