Provider First Line Business Practice Location Address:
1448 E CENTER ST
Provider Second Line Business Practice Location Address:
SUITE A-1
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-1100
Provider Business Practice Location Address Fax Number:
208-233-4933
Provider Enumeration Date:
04/03/2007