Provider First Line Business Practice Location Address:
4750 YELLOWSTONE AVE STE A
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:
83202-2336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-1720
Provider Business Practice Location Address Fax Number:
208-233-2161
Provider Enumeration Date:
12/04/2023