Provider First Line Business Practice Location Address:
540 W SUNNYSIDE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-9839
Provider Business Practice Location Address Fax Number:
208-522-0224
Provider Enumeration Date:
08/12/2010