Provider First Line Business Practice Location Address:
1340 S. AMMON ROAD
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:
83406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-3141
Provider Business Practice Location Address Fax Number:
208-525-2661
Provider Enumeration Date:
11/29/2006