Provider First Line Business Practice Location Address:
850 E CENTER ST STE B
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:
83201-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-251-0226
Provider Business Practice Location Address Fax Number:
208-251-3282
Provider Enumeration Date:
03/29/2007