Provider First Line Business Practice Location Address:
2420 E 25TH ST STE A
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:
83404-7549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-1026
Provider Business Practice Location Address Fax Number:
208-557-7494
Provider Enumeration Date:
10/05/2006