Provider First Line Business Practice Location Address:
2001 BENCH RD
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:
83201-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-646-3160
Provider Business Practice Location Address Fax Number:
208-646-3161
Provider Enumeration Date:
07/08/2020