Provider First Line Business Practice Location Address:
3696 S HOLMES 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:
83404-7911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-2374
Provider Business Practice Location Address Fax Number:
208-524-0867
Provider Enumeration Date:
04/27/2007