Provider First Line Business Practice Location Address:
2496 MESA 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:
83401-3369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-251-7885
Provider Business Practice Location Address Fax Number:
208-745-0527
Provider Enumeration Date:
05/21/2007