Provider First Line Business Practice Location Address:
2300 N YELLOWSTONE HWY STE 104
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:
83401-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-538-1963
Provider Business Practice Location Address Fax Number:
208-615-8005
Provider Enumeration Date:
08/23/2013