Provider First Line Business Practice Location Address:
115 S 15TH 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:
83201-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-4310
Provider Business Practice Location Address Fax Number:
208-233-4368
Provider Enumeration Date:
12/03/2015