Provider First Line Business Practice Location Address:
732 WASHINGTON 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:
83201-3748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-604-0098
Provider Business Practice Location Address Fax Number:
208-637-1577
Provider Enumeration Date:
03/28/2014