Provider First Line Business Practice Location Address:
850 E LANDER ST
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:
83201-5763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-2094
Provider Business Practice Location Address Fax Number:
208-234-2637
Provider Enumeration Date:
04/11/2007