Provider First Line Business Practice Location Address:
2300 N YELLOWSTONE HWY
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:
83401-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-503-7712
Provider Business Practice Location Address Fax Number:
208-615-8005
Provider Enumeration Date:
03/12/2013