Provider First Line Business Practice Location Address:
454 FRANKLIN AVE
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:
83201-3845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-244-9002
Provider Business Practice Location Address Fax Number:
208-427-9331
Provider Enumeration Date:
07/30/2010