Provider First Line Business Practice Location Address:
8000 S 55TH W
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:
83402-5733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-613-7361
Provider Business Practice Location Address Fax Number:
843-892-8444
Provider Enumeration Date:
06/09/2025