Provider First Line Business Practice Location Address:
3760 WASHINGTON PKWY
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:
83404-7593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-3637
Provider Business Practice Location Address Fax Number:
208-522-2705
Provider Enumeration Date:
02/21/2017