Provider First Line Business Practice Location Address:
200 N WOODRUFF AVE
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:
83401-4334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-0120
Provider Business Practice Location Address Fax Number:
208-523-4711
Provider Enumeration Date:
05/11/2006