Provider First Line Business Practice Location Address:
2381 E SUNNYSIDE 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:
83404-7521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-8500
Provider Business Practice Location Address Fax Number:
208-523-8502
Provider Enumeration Date:
02/29/2012