Provider First Line Business Practice Location Address:
348 W CLARK 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:
83204-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-242-3376
Provider Business Practice Location Address Fax Number:
208-242-3245
Provider Enumeration Date:
07/30/2019