Provider First Line Business Practice Location Address:
2225 TETON PLZ
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4660
Provider Business Practice Location Address Fax Number:
208-524-4617
Provider Enumeration Date:
06/10/2005