Provider First Line Business Practice Location Address:
2100 ALAN 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:
83404-5801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-7655
Provider Business Practice Location Address Fax Number:
208-524-9390
Provider Enumeration Date:
02/10/2014