Provider First Line Business Practice Location Address:
2210 CORONADO 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:
83404-7430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-3355
Provider Business Practice Location Address Fax Number:
208-522-6019
Provider Enumeration Date:
01/12/2016