Provider First Line Business Practice Location Address:
3442 S. 15TH E.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-1222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2015