Provider First Line Business Practice Location Address:
3652 WASHINGTON PKWY
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-419-0593
Provider Business Practice Location Address Fax Number:
208-524-1222
Provider Enumeration Date:
03/29/2012