Provider First Line Business Practice Location Address:
250 N 5TH AVE
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:
83201-6278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-1353
Provider Business Practice Location Address Fax Number:
208-478-1957
Provider Enumeration Date:
02/19/2008