Provider First Line Business Practice Location Address:
3200 CHANNING WAY STE 206
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:
83404-7546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-2230
Provider Business Practice Location Address Fax Number:
208-453-6142
Provider Enumeration Date:
01/11/2021