Provider First Line Business Practice Location Address:
2424 BIRDIE THOMPSON DRIVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-0481
Provider Business Practice Location Address Fax Number:
775-307-4049
Provider Enumeration Date:
10/01/2012