Provider First Line Business Practice Location Address:
564 S WOODRUFF AVENUE
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:
208-523-7571
Provider Business Practice Location Address Fax Number:
208-523-7573
Provider Enumeration Date:
04/05/2018