Provider First Line Business Practice Location Address:
187 E. 13TH ST.
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:
208-497-0500
Provider Business Practice Location Address Fax Number:
208-497-0198
Provider Enumeration Date:
11/08/2006