Provider First Line Business Practice Location Address:
3360 WASHINGTON PKWY STE 2
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:
83404-8333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-932-7024
Provider Business Practice Location Address Fax Number:
208-904-4447
Provider Enumeration Date:
01/05/2019