Provider First Line Business Practice Location Address:
2065 E 17TH ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-0747
Provider Business Practice Location Address Fax Number:
208-522-9641
Provider Enumeration Date:
09/09/2009