Provider First Line Business Practice Location Address:
707 NORTH 7TH
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:
208-233-4562
Provider Business Practice Location Address Fax Number:
208-234-4638
Provider Enumeration Date:
11/29/2006