Provider First Line Business Practice Location Address:
2275 W BROADWAY ST STE G
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:
83402-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-7400
Provider Business Practice Location Address Fax Number:
208-534-5715
Provider Enumeration Date:
06/17/2022