Provider First Line Business Practice Location Address:
1075 S UTAH AVE STE 356
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:
83402-3334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-541-4295
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2014