Provider First Line Business Practice Location Address:
180 N WOODRUFF AVE
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:
83401-4335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-346-0688
Provider Business Practice Location Address Fax Number:
208-620-3027
Provider Enumeration Date:
11/09/2021