Provider First Line Business Practice Location Address:
445 N CAPITAL AVE STE 8
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:
83402-3652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-2848
Provider Business Practice Location Address Fax Number:
208-542-5295
Provider Enumeration Date:
07/02/2007