Provider First Line Business Practice Location Address:
187 E 13TH ST
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:
83404-5305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-497-0500
Provider Business Practice Location Address Fax Number:
208-497-0198
Provider Enumeration Date:
10/06/2019