Provider First Line Business Practice Location Address:
351 E 14TH 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:
83404-5911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-787-4862
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2026