Provider First Line Business Practice Location Address:
254 E ST STE B
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:
83402-3527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-339-0816
Provider Business Practice Location Address Fax Number:
208-523-5974
Provider Enumeration Date:
05/21/2013