Provider First Line Business Practice Location Address:
1951 BENCH RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-2073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-2080
Provider Business Practice Location Address Fax Number:
208-237-1084
Provider Enumeration Date:
04/07/2006