Provider First Line Business Practice Location Address:
3500 POTOMAC WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-4974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-7666
Provider Business Practice Location Address Fax Number:
208-524-2821
Provider Enumeration Date:
01/18/2012