Provider First Line Business Practice Location Address:
1820 E 17TH ST STE 190
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:
83404-6518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-419-6102
Provider Business Practice Location Address Fax Number:
208-542-8004
Provider Enumeration Date:
04/19/2012