Provider First Line Business Practice Location Address:
415 S ARTHUR 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:
83204-3303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-6833
Provider Business Practice Location Address Fax Number:
208-233-6842
Provider Enumeration Date:
05/14/2007