Provider First Line Business Practice Location Address:
1542 ELK CREEK DR
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:
83404-8322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1620
Provider Business Practice Location Address Fax Number:
208-523-1497
Provider Enumeration Date:
09/04/2006