Provider First Line Business Practice Location Address:
2235 E 25TH ST
Provider Second Line Business Practice Location Address:
SUITE 185
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-1904
Provider Business Practice Location Address Fax Number:
208-522-8847
Provider Enumeration Date:
01/23/2012