Provider First Line Business Practice Location Address:
2225 TETON PLZ 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:
83404-6494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-4300
Provider Business Practice Location Address Fax Number:
208-529-1627
Provider Enumeration Date:
10/28/2008