Provider First Line Business Practice Location Address:
490 PARK AVE STE 4
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:
83402-1230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-339-4356
Provider Business Practice Location Address Fax Number:
208-612-5035
Provider Enumeration Date:
05/22/2025