Provider First Line Business Practice Location Address:
9915 N 26TH E
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:
83401-6435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-521-8389
Provider Business Practice Location Address Fax Number:
208-271-8882
Provider Enumeration Date:
03/14/2025