Provider First Line Business Practice Location Address:
1075 S UTAH AVE STE 354
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:
83402-3320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-5777
Provider Business Practice Location Address Fax Number:
208-529-5778
Provider Enumeration Date:
02/19/2006