Provider First Line Business Practice Location Address:
120 NORTHGATE MILE
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:
83401-2543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-932-3753
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2011