Provider First Line Business Practice Location Address:
1246 YELLOWSTONE AVE BLDG F
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:
83201-4374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-9194
Provider Business Practice Location Address Fax Number:
208-237-2646
Provider Enumeration Date:
03/19/2020