Provider First Line Business Practice Location Address:
115 E CHAPEL ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-6848
Provider Business Practice Location Address Fax Number:
208-237-6811
Provider Enumeration Date:
10/24/2006