Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE RD STE J
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:
83404-8281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-7246
Provider Business Practice Location Address Fax Number:
208-529-2620
Provider Enumeration Date:
03/12/2012