Provider First Line Business Practice Location Address:
1420 E 17TH ST STE 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:
83404-6283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-5434
Provider Business Practice Location Address Fax Number:
208-522-4364
Provider Enumeration Date:
05/08/2012