Provider First Line Business Practice Location Address:
550 2ND ST STE 229
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:
83401-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-643-3639
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2019