Provider First Line Business Practice Location Address:
560 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-0258
Provider Business Practice Location Address Fax Number:
208-269-7336
Provider Enumeration Date:
05/04/2007