Provider First Line Business Practice Location Address:
2394 COURTNEY 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:
83201-7920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-281-7616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2025