Provider First Line Business Practice Location Address:
665 S 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:
83401-5596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4552
Provider Business Practice Location Address Fax Number:
208-524-4559
Provider Enumeration Date:
07/08/2009