Provider First Line Business Practice Location Address:
2225 TETON PLZ STE A
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:
83404-6494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-4831
Provider Business Practice Location Address Fax Number:
208-529-4189
Provider Enumeration Date:
09/21/2006