Provider First Line Business Practice Location Address:
1348 E 17TH ST
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:
83404-6270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-6564
Provider Business Practice Location Address Fax Number:
208-542-6571
Provider Enumeration Date:
12/26/2006