Provider First Line Business Practice Location Address:
2235 E 25TH ST STE 290
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:
83404-7595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-0490
Provider Business Practice Location Address Fax Number:
208-552-2518
Provider Enumeration Date:
09/29/2006