Provider First Line Business Practice Location Address:
150 SHOUP AVE
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-3657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-528-5700
Provider Business Practice Location Address Fax Number:
208-528-5747
Provider Enumeration Date:
04/06/2017