Provider First Line Business Practice Location Address:
1542 ELK CREEK DR
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:
83404-8322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
986-275-0142
Provider Business Practice Location Address Fax Number:
307-333-0299
Provider Enumeration Date:
03/31/2026