Provider First Line Business Practice Location Address:
1800 GARRETT WAY
Provider Second Line Business Practice Location Address:
STE 19A
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-1064
Provider Business Practice Location Address Fax Number:
208-233-0219
Provider Enumeration Date:
08/14/2007