Provider First Line Business Practice Location Address:
3400 SOUTH 5TH WEST
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-8500
Provider Business Practice Location Address Fax Number:
208-520-2916
Provider Enumeration Date:
09/07/2007