Provider First Line Business Practice Location Address:
151 N 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-269-7147
Provider Business Practice Location Address Fax Number:
208-416-6522
Provider Enumeration Date:
10/04/2006