Provider First Line Business Practice Location Address:
1880 E 17TH ST
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:
83404-6468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-0121
Provider Business Practice Location Address Fax Number:
208-529-0001
Provider Enumeration Date:
03/09/2011