Provider First Line Business Practice Location Address:
1169 CALL CREEK PL. SUITE B
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-7780
Provider Business Practice Location Address Fax Number:
208-232-7782
Provider Enumeration Date:
01/17/2007