Provider First Line Business Practice Location Address:
1301 E 17TH 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:
83404-6273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-538-3122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2012