Provider First Line Business Practice Location Address:
2434 S FAIRWAY DR
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:
83201-2372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-851-9151
Provider Business Practice Location Address Fax Number:
208-417-1822
Provider Enumeration Date:
08/21/2009