Provider First Line Business Practice Location Address:
147 STANFORD 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:
83201-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-649-4171
Provider Business Practice Location Address Fax Number:
208-646-4394
Provider Enumeration Date:
10/05/2023