Provider First Line Business Practice Location Address:
1445 N WOOD RIVER DRIVE
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:
83401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-0397
Provider Business Practice Location Address Fax Number:
208-529-2755
Provider Enumeration Date:
10/16/2008