Provider First Line Business Practice Location Address:
3200 CHANNING WAY
Provider Second Line Business Practice Location Address:
STE A201
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3278
Provider Business Practice Location Address Fax Number:
208-524-6033
Provider Enumeration Date:
12/27/2011