Provider First Line Business Practice Location Address:
2860 CHANNING WAY
Provider Second Line Business Practice Location Address:
SUITE 114A
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-4565
Provider Business Practice Location Address Fax Number:
208-535-4564
Provider Enumeration Date:
09/16/2008