Provider First Line Business Practice Location Address:
850 ENERGY PL STE 1
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:
83401-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-346-7807
Provider Business Practice Location Address Fax Number:
208-346-7790
Provider Enumeration Date:
04/28/2009