Provider First Line Business Practice Location Address:
329 S WOODRUFF 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:
83401-4322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-881-0085
Provider Business Practice Location Address Fax Number:
208-881-0075
Provider Enumeration Date:
09/02/2021