Provider First Line Business Practice Location Address:
921 S. 8TH AVE
Provider Second Line Business Practice Location Address:
MAIL STOP 8116
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-8116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-2219
Provider Business Practice Location Address Fax Number:
208-282-4571
Provider Enumeration Date:
11/30/2006