Provider First Line Business Practice Location Address:
400 S WOODRUFF AVE
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:
83401-4367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-5300
Provider Business Practice Location Address Fax Number:
209-529-0940
Provider Enumeration Date:
11/09/2011