Provider First Line Business Practice Location Address:
3715 WOODKING 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:
83404-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-520-2242
Provider Business Practice Location Address Fax Number:
208-529-2022
Provider Enumeration Date:
07/29/2014