Provider First Line Business Practice Location Address:
211 S. WOODRUFF AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-534-8303
Provider Business Practice Location Address Fax Number:
208-575-0300
Provider Enumeration Date:
03/19/2015