Provider First Line Business Practice Location Address:
3549 N AMMON RD
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:
83401-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-4414
Provider Business Practice Location Address Fax Number:
208-525-4487
Provider Enumeration Date:
11/03/2005