Provider First Line Business Practice Location Address:
1135 YELLOWSTONE AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-2908
Provider Business Practice Location Address Fax Number:
208-232-5423
Provider Enumeration Date:
09/05/2011