Provider First Line Business Practice Location Address:
353 N. 4TH AVENUE
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-6392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-6677
Provider Business Practice Location Address Fax Number:
208-478-2618
Provider Enumeration Date:
04/23/2008