Provider First Line Business Practice Location Address: 
1001 N 7TH AVE # ATE135
    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: 
83201-5761
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-232-7862
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/16/2021