Provider First Line Business Practice Location Address:
2052 JENNIE LEE DR
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:
83404-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-227-0478
Provider Business Practice Location Address Fax Number:
208-227-0479
Provider Enumeration Date:
10/18/2012