Provider First Line Business Practice Location Address:
2860 CHANNING WAY
Provider Second Line Business Practice Location Address:
STE 117
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-2470
Provider Business Practice Location Address Fax Number:
208-523-1118
Provider Enumeration Date:
07/21/2005