Provider First Line Business Practice Location Address:
1230 N SKYLINE, STE A
Provider Second Line Business Practice Location Address:
1230 N SKYLINE, STE A
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-0881
Provider Business Practice Location Address Fax Number:
208-524-0886
Provider Enumeration Date:
05/25/2006