Provider First Line Business Practice Location Address:
690 YELLOWSTONE AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-1413
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007