Provider First Line Business Practice Location Address:
500 SOUTH 11TH AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-3480
Provider Business Practice Location Address Fax Number:
208-233-6585
Provider Enumeration Date:
10/24/2006