Provider First Line Business Practice Location Address:
1820 E 17TH
Provider Second Line Business Practice Location Address:
STE 330
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-497-0685
Provider Business Practice Location Address Fax Number:
208-497-0506
Provider Enumeration Date:
02/06/2008