Provider First Line Business Practice Location Address:
630 S WOODRUFF AVE STE B
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:
83401-6472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-688-0564
Provider Business Practice Location Address Fax Number:
208-529-2148
Provider Enumeration Date:
01/03/2008