Provider First Line Business Practice Location Address:
477 SHOUP AVE STE 107B
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:
83402-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-1914
Provider Business Practice Location Address Fax Number:
208-522-1956
Provider Enumeration Date:
05/17/2007