Provider First Line Business Practice Location Address:
675 E ANDERSON 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:
83401-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-419-9238
Provider Business Practice Location Address Fax Number:
208-598-7998
Provider Enumeration Date:
02/05/2025