Provider First Line Business Practice Location Address:
348 S 1ST AVE
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:
83201-6414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-2357
Provider Business Practice Location Address Fax Number:
208-235-1503
Provider Enumeration Date:
08/17/2007