Provider First Line Business Practice Location Address:
1951 BENCH RD
Provider Second Line Business Practice Location Address:
#C
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:
208-238-3377
Provider Business Practice Location Address Fax Number:
208-238-8091
Provider Enumeration Date:
08/26/2006