Provider First Line Business Practice Location Address:
1970 E 17TH ST
Provider Second Line Business Practice Location Address:
STE. 202
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-5319
Provider Business Practice Location Address Fax Number:
208-523-5627
Provider Enumeration Date:
09/10/2014