Provider First Line Business Practice Location Address:
620 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:
83401-5299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-419-3408
Provider Business Practice Location Address Fax Number:
208-419-3412
Provider Enumeration Date:
08/19/2015