Provider First Line Business Practice Location Address:
196 PARK 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:
83201-4619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-0067
Provider Business Practice Location Address Fax Number:
208-233-9275
Provider Enumeration Date:
08/30/2006