Provider First Line Business Practice Location Address:
3652 WASHINGTON PKWY
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:
83404-7573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-8700
Provider Business Practice Location Address Fax Number:
208-528-2802
Provider Enumeration Date:
07/31/2007