Provider First Line Business Practice Location Address:
2194 SNAKE RIVER PKWY STE 101
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:
83402-4351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-757-6245
Provider Business Practice Location Address Fax Number:
208-757-6264
Provider Enumeration Date:
04/22/2021