Provider First Line Business Practice Location Address:
765 S UTAH AVE
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:
83402-5093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-2600
Provider Business Practice Location Address Fax Number:
208-525-2611
Provider Enumeration Date:
02/29/2012