Provider First Line Business Practice Location Address:
3550 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:
83404-4968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-2300
Provider Business Practice Location Address Fax Number:
208-545-8447
Provider Enumeration Date:
06/12/2007