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:
208-552-4958
Provider Business Practice Location Address Fax Number:
208-552-7704
Provider Enumeration Date:
06/28/2007