Provider First Line Business Practice Location Address:
2030 JENNIE LEE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-8879
Provider Business Practice Location Address Fax Number:
208-523-0436
Provider Enumeration Date:
05/30/2008