Provider First Line Business Practice Location Address:
5136 S 45TH W
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:
83402-5715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-317-2926
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2026