Provider First Line Business Practice Location Address:
500 S UTAH 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:
83402-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-8703
Provider Business Practice Location Address Fax Number:
208-528-8695
Provider Enumeration Date:
10/25/2015