Provider First Line Business Practice Location Address:
1278 S WOODRUFF AVE
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:
83404-5544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3018
Provider Business Practice Location Address Fax Number:
208-524-3019
Provider Enumeration Date:
04/04/2007