Provider First Line Business Practice Location Address:
2250 CORONADO ST
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:
83404-7552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-7979
Provider Business Practice Location Address Fax Number:
208-523-2238
Provider Enumeration Date:
05/31/2005