Provider First Line Business Practice Location Address:
1950 E CLARK ST
Provider Second Line Business Practice Location Address:
STE A
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:
208-232-5550
Provider Business Practice Location Address Fax Number:
208-232-5553
Provider Enumeration Date:
08/31/2006