Provider First Line Business Practice Location Address:
3814 WASHINGTON PKWY
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:
83404-7591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-3562
Provider Business Practice Location Address Fax Number:
208-529-4064
Provider Enumeration Date:
04/18/2007