Provider First Line Business Practice Location Address:
1846 1ST ST. SUITE 242
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:
83401-9599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-861-7841
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2024