Provider First Line Business Practice Location Address:
115 S 15TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-0012
Provider Business Practice Location Address Fax Number:
208-478-7877
Provider Enumeration Date:
03/06/2007