Provider First Line Business Practice Location Address:
211 S WOODRUFF AVE STE B
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:
83401-4369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-2122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2006