Provider First Line Business Practice Location Address:
13816 N 65TH E
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:
83401-5319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-8688
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2023