Provider First Line Business Practice Location Address:
333 N 18TH AVE
Provider Second Line Business Practice Location Address:
# B-3
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-3358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-2146
Provider Business Practice Location Address Fax Number:
208-232-2770
Provider Enumeration Date:
09/19/2005