Provider First Line Business Practice Location Address:
1522 ELK CREEK DR
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:
83404-8322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-0920
Provider Business Practice Location Address Fax Number:
208-529-2564
Provider Enumeration Date:
05/20/2008