Provider First Line Business Practice Location Address:
2860 CHANNING WAY STE 224
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:
83404-7541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-6430
Provider Business Practice Location Address Fax Number:
208-529-6428
Provider Enumeration Date:
03/13/2009