Provider First Line Business Practice Location Address:
1135 YELLOWSTONE AVE STE D
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:
83201-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-9400
Provider Business Practice Location Address Fax Number:
208-238-9401
Provider Enumeration Date:
05/08/2007