Provider First Line Business Practice Location Address:
550 2ND ST # 292
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:
83401-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-200-7377
Provider Business Practice Location Address Fax Number:
208-529-4647
Provider Enumeration Date:
04/23/2007