Provider First Line Business Practice Location Address:
550 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 292
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2211
Provider Business Practice Location Address Fax Number:
208-529-4647
Provider Enumeration Date:
05/20/2007