Provider First Line Business Practice Location Address:
294 1/2 W 20TH ST
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:
83402-4457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-840-9582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/03/2026