Provider First Line Business Practice Location Address:
3360 WASHINGTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-8170
Provider Business Practice Location Address Fax Number:
208-552-5461
Provider Enumeration Date:
09/09/2011