Provider First Line Business Practice Location Address:
2205 CHANNING WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-3660
Provider Business Practice Location Address Fax Number:
208-529-3666
Provider Enumeration Date:
11/07/2006