Provider First Line Business Practice Location Address:
554 4TH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-2380
Provider Business Practice Location Address Fax Number:
208-523-2380
Provider Enumeration Date:
01/07/2008