Provider First Line Business Practice Location Address:
2265 DESOTO 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:
83404-7540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-569-7139
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2026