Provider First Line Business Practice Location Address:
1455 BENCH RD
Provider Second Line Business Practice Location Address:
SUITE B
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:
208-232-0006
Provider Business Practice Location Address Fax Number:
208-233-8771
Provider Enumeration Date:
11/02/2006