Provider First Line Business Practice Location Address:
115 S. 15TH
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-7558
Provider Business Practice Location Address Fax Number:
208-232-7549
Provider Enumeration Date:
09/05/2006