Provider First Line Business Practice Location Address:
GARRISON BLDG 63 RM 201
Provider Second Line Business Practice Location Address:
CAMPUS STOP 8045
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-8045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-2590
Provider Business Practice Location Address Fax Number:
208-282-4962
Provider Enumeration Date:
11/11/2013