Provider First Line Business Practice Location Address:
675 YELLOWSTONE AVE
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:
83201-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-4449
Provider Business Practice Location Address Fax Number:
208-478-1181
Provider Enumeration Date:
08/19/2006