Provider First Line Business Practice Location Address:
111 E 16TH ST
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:
83404-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1130
Provider Business Practice Location Address Fax Number:
208-529-6501
Provider Enumeration Date:
10/01/2008