Provider First Line Business Practice Location Address:
3614 WASHINGTON PKWY
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:
83404-7573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-3633
Provider Business Practice Location Address Fax Number:
208-535-3634
Provider Enumeration Date:
09/18/2017