Provider First Line Business Practice Location Address:
1480 E LINCOLN RD STE B
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:
83401-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-8686
Provider Business Practice Location Address Fax Number:
208-525-8684
Provider Enumeration Date:
12/08/2011