Provider First Line Business Practice Location Address:
3729 WOODKING DR STE 1
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:
83404-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-4900
Provider Business Practice Location Address Fax Number:
208-612-6118
Provider Enumeration Date:
02/18/2014