Provider First Line Business Practice Location Address:
3100 CHANNING WAY
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-487-0277
Provider Business Practice Location Address Fax Number:
770-701-6674
Provider Enumeration Date:
05/27/2008