Provider First Line Business Practice Location Address:
535 W SUNNYSIDE RD
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:
83402-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2019
Provider Business Practice Location Address Fax Number:
208-392-4095
Provider Enumeration Date:
12/30/2021