Provider First Line Business Practice Location Address:
2001 S. WOODRUFF STE. 6
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:
83402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-4673
Provider Business Practice Location Address Fax Number:
208-529-4676
Provider Enumeration Date:
06/23/2011