Provider First Line Business Practice Location Address:
3400 S 5TH W
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:
83402-7309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-220-8327
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2025