Provider First Line Business Practice Location Address:
1740 E 17TH ST STE B
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:
83404-6375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-8832
Provider Business Practice Location Address Fax Number:
208-522-8725
Provider Enumeration Date:
07/13/2006