Provider First Line Business Practice Location Address:
1380 LATAH AVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-0919
Provider Business Practice Location Address Fax Number:
208-552-1010
Provider Enumeration Date:
05/22/2009