Provider First Line Business Practice Location Address:
510 E 17TH ST # 400
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:
83404-6154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-589-0807
Provider Business Practice Location Address Fax Number:
208-542-9577
Provider Enumeration Date:
10/13/2006