Provider First Line Business Practice Location Address:
120 S RAILROAD 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:
83204-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-236-5396
Provider Business Practice Location Address Fax Number:
208-236-5201
Provider Enumeration Date:
01/19/2006