Provider First Line Business Practice Location Address:
1020 LAND BANK ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-6155
Provider Business Practice Location Address Fax Number:
208-522-6156
Provider Enumeration Date:
10/08/2015