Provider First Line Business Practice Location Address:
1784 SCIENCE CENTER DR
Provider Second Line Business Practice Location Address:
IDAHO STATE UNIVERSITY
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-1575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-7826
Provider Business Practice Location Address Fax Number:
208-282-7850
Provider Enumeration Date:
11/29/2006