Provider First Line Business Practice Location Address:
545 SHOUP AVE STE 224
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:
83402-3482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-3939
Provider Business Practice Location Address Fax Number:
208-216-0230
Provider Enumeration Date:
05/19/2022