Provider First Line Business Practice Location Address:
780 BRIDGEPORT DR
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:
83402-3370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-932-4600
Provider Business Practice Location Address Fax Number:
208-932-4601
Provider Enumeration Date:
06/20/2025