Provider First Line Business Practice Location Address:
1995 E 17TH ST #1
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-9193
Provider Business Practice Location Address Fax Number:
208-357-9173
Provider Enumeration Date:
07/27/2016