Provider First Line Business Practice Location Address:
638 E. DUNN ST.
Provider Second Line Business Practice Location Address:
IDAHO STATE UNIVERSITY
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-8116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-4037
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2006