Provider First Line Business Practice Location Address:
3155 CHANNING WAY 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:
83404-7875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-6044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2015