Provider First Line Business Practice Location Address:
1352 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:
83201-4734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-2001
Provider Business Practice Location Address Fax Number:
208-232-2195
Provider Enumeration Date:
08/20/2006