Provider First Line Business Practice Location Address:
1970 E 17TH ST STE 201
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:
83404-8048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2734
Provider Business Practice Location Address Fax Number:
208-529-2833
Provider Enumeration Date:
04/08/2020