Provider First Line Business Practice Location Address:
1301 E. W. 17TH ST.
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:
83404-8340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-716-2742
Provider Business Practice Location Address Fax Number:
208-538-3122
Provider Enumeration Date:
12/22/2021