Provider First Line Business Practice Location Address:
165 N 14TH 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:
83201-4146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-2807
Provider Business Practice Location Address Fax Number:
208-232-8118
Provider Enumeration Date:
11/17/2006