Provider First Line Business Practice Location Address:
408 E WHITMAN ST
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:
83201-6450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-6200
Provider Business Practice Location Address Fax Number:
208-233-4043
Provider Enumeration Date:
11/23/2005