Provider First Line Business Practice Location Address:
1320 S AMMON ROAD
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:
83406-5810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2084
Provider Business Practice Location Address Fax Number:
208-529-2084
Provider Enumeration Date:
02/15/2006