Provider First Line Business Practice Location Address:
650 W SUNNYSIDE RD
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:
83402-4761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-3113
Provider Business Practice Location Address Fax Number:
208-552-9668
Provider Enumeration Date:
12/20/2006