Provider First Line Business Practice Location Address:
500 S 11TH AVE
Provider Second Line Business Practice Location Address:
STE 501
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:
208-232-7434
Provider Business Practice Location Address Fax Number:
208-233-6446
Provider Enumeration Date:
10/03/2006