Provider First Line Business Practice Location Address:
3345 MERLIN DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-4481
Provider Business Practice Location Address Fax Number:
208-522-6137
Provider Enumeration Date:
06/08/2006