Provider First Line Business Practice Location Address:
1465 HOOPES 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:
83404-5772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-5545
Provider Business Practice Location Address Fax Number:
208-528-6773
Provider Enumeration Date:
10/30/2007