Provider First Line Business Practice Location Address:
201 E CENTER ST
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:
83201-6339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-6101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2011