Provider First Line Business Practice Location Address:
1130 CALL CREEK DRIVE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-8410
Provider Business Practice Location Address Fax Number:
208-233-4952
Provider Enumeration Date:
10/31/2006