Provider First Line Business Practice Location Address:
250 SOUTH SKYINE DRIVE
Provider Second Line Business Practice Location Address:
STE 4
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:
208-524-1404
Provider Business Practice Location Address Fax Number:
208-524-1114
Provider Enumeration Date:
02/15/2007