Provider First Line Business Practice Location Address:
1361 CAMBRIDGE 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:
83401-4208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-7566
Provider Business Practice Location Address Fax Number:
208-523-9224
Provider Enumeration Date:
12/21/2006