Provider First Line Business Practice Location Address:
5230 W MOONLIGHT MINE RD.
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:
83201-8320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-351-3956
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2012