Provider First Line Business Practice Location Address:
3910 S YELLOWSTONE HWY STE 111
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:
83402-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-358-8313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2026