Provider First Line Business Practice Location Address:
1155 POCATELLO CREEK RD
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:
83201-2949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-2020
Provider Business Practice Location Address Fax Number:
208-233-2021
Provider Enumeration Date:
09/23/2005