Provider First Line Business Practice Location Address:
2001 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-885-0828
Provider Business Practice Location Address Fax Number:
417-886-7383
Provider Enumeration Date:
07/23/2007