Provider First Line Business Practice Location Address:
2006 BIRDIE THOMPSON DR
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:
83201-2768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-1132
Provider Business Practice Location Address Fax Number:
208-232-1134
Provider Enumeration Date:
11/15/2006