Provider First Line Business Practice Location Address:
1470 HOLLIPARK DR STE A
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:
83401-2160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-754-2127
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2026