Provider First Line Business Practice Location Address:
2001 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
SUITE 12A
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:
208-524-2255
Provider Business Practice Location Address Fax Number:
208-524-2256
Provider Enumeration Date:
07/26/2005