Provider First Line Business Practice Location Address:
3686 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:
83404-7573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-747-5500
Provider Business Practice Location Address Fax Number:
801-747-5592
Provider Enumeration Date:
11/13/2006