Provider First Line Business Practice Location Address:
505 1ST STREET, SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-6002
Provider Business Practice Location Address Fax Number:
208-232-2558
Provider Enumeration Date:
07/27/2009