Provider First Line Business Practice Location Address:
645 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-9886
Provider Business Practice Location Address Fax Number:
208-718-9847
Provider Enumeration Date:
10/02/2024