Provider First Line Business Practice Location Address:
275 N WOODRUFF AVE
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:
83401-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-604-0973
Provider Business Practice Location Address Fax Number:
208-228-6282
Provider Enumeration Date:
03/17/2008