Provider First Line Business Practice Location Address:
496 A ST
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:
83402-3617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-7100
Provider Business Practice Location Address Fax Number:
208-552-7101
Provider Enumeration Date:
08/20/2006