Provider First Line Business Practice Location Address:
1820 E 17TH ST STE 365
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:
83404-6497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-403-2825
Provider Business Practice Location Address Fax Number:
208-542-5152
Provider Enumeration Date:
12/04/2007