Provider First Line Business Practice Location Address:
333 N 18TH AVE STE B4
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:
83201-3322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-8000
Provider Business Practice Location Address Fax Number:
208-478-8801
Provider Enumeration Date:
03/12/2007