Provider First Line Business Practice Location Address:
1380 BENTON ST
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:
83401-4254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-403-3472
Provider Business Practice Location Address Fax Number:
208-522-2603
Provider Enumeration Date:
03/13/2007