Provider First Line Business Practice Location Address:
141 N 6TH AVE
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:
83201-6209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-236-7089
Provider Business Practice Location Address Fax Number:
208-236-7097
Provider Enumeration Date:
05/26/2015