Provider First Line Business Practice Location Address:
342 YELLOWSTONE AVE
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:
83201-4530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-479-1996
Provider Business Practice Location Address Fax Number:
801-880-4448
Provider Enumeration Date:
01/18/2008