Provider First Line Business Practice Location Address:
3425 POTOMAC WAY
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:
83404-4970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-8170
Provider Business Practice Location Address Fax Number:
208-552-5461
Provider Enumeration Date:
11/02/2006