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:
83404-7533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-863-9595
Provider Business Practice Location Address Fax Number:
706-868-8375
Provider Enumeration Date:
10/08/2018