Provider First Line Business Practice Location Address:
381 SHOUP AVE STE 202
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:
83402-3651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-497-1290
Provider Business Practice Location Address Fax Number:
208-497-1290
Provider Enumeration Date:
08/22/2017