Provider First Line Business Practice Location Address:
2105 CORONADO STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-534-7881
Provider Business Practice Location Address Fax Number:
208-242-4464
Provider Enumeration Date:
11/15/2023