Provider First Line Business Practice Location Address:
1680 ELK CREEK DR
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:
83404-1225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-0685
Provider Business Practice Location Address Fax Number:
208-524-0686
Provider Enumeration Date:
05/27/2009