Provider First Line Business Practice Location Address:
1885 PARKWOOD 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:
83401-6135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-7800
Provider Business Practice Location Address Fax Number:
208-523-2240
Provider Enumeration Date:
02/27/2007