Provider First Line Business Practice Location Address:
999 MARTIN LUTHER KING JR. WAY
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:
83209-8048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-3282
Provider Business Practice Location Address Fax Number:
208-282-5355
Provider Enumeration Date:
04/19/2007