Provider First Line Business Practice Location Address:
1448 E CENTER ST STE A1
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:
83201-4132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-4642
Provider Business Practice Location Address Fax Number:
207-232-8001
Provider Enumeration Date:
05/06/2009