Provider First Line Business Practice Location Address:
1448 E CENTER ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-1300
Provider Business Practice Location Address Fax Number:
208-234-1333
Provider Enumeration Date:
08/22/2005