Provider First Line Business Practice Location Address:
2001 S WOODRUFF AVE STE 20
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:
83404-6373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-3050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2019