Provider First Line Business Practice Location Address:
2280 E 25TH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-227-2295
Provider Business Practice Location Address Fax Number:
208-227-2364
Provider Enumeration Date:
02/24/2006