Provider First Line Business Practice Location Address:
258 N WATER AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-4057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-0077
Provider Business Practice Location Address Fax Number:
208-522-3797
Provider Enumeration Date:
08/18/2006