Provider First Line Business Practice Location Address:
535 W SUNNYSIDE RD STE 2
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:
83402-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-291-1208
Provider Business Practice Location Address Fax Number:
800-861-3329
Provider Enumeration Date:
03/04/2026