Provider First Line Business Practice Location Address:
1920 E 17TH ST STE 240
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:
83404-8036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-589-8690
Provider Business Practice Location Address Fax Number:
208-523-8978
Provider Enumeration Date:
06/22/2017