Provider First Line Business Practice Location Address:
421 E OAK 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:
83201-4601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-241-7496
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2012