Provider First Line Business Practice Location Address:
1753 W BROADWAY 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:
83402-3045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4445
Provider Business Practice Location Address Fax Number:
208-522-5005
Provider Enumeration Date:
05/20/2024