Provider First Line Business Practice Location Address:
2043 E CENTER ST STE 211
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:
83201-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-4953
Provider Business Practice Location Address Fax Number:
208-524-7335
Provider Enumeration Date:
02/06/2008