Provider First Line Business Practice Location Address:
3425 MERLIN DR STE 200
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:
83404-7430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-6653
Provider Business Practice Location Address Fax Number:
208-528-6676
Provider Enumeration Date:
12/12/2006