Provider First Line Business Practice Location Address:
1525 WESTLAND AVE
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:
83402-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-530-0654
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2025