Provider First Line Business Practice Location Address:
3607 POLE LINE RD
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:
83201-5531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-637-1662
Provider Business Practice Location Address Fax Number:
208-637-1554
Provider Enumeration Date:
04/18/2007