Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE RD STE F2
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:
83404-8280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-623-8614
Provider Business Practice Location Address Fax Number:
208-572-7540
Provider Enumeration Date:
01/27/2022