Provider First Line Business Practice Location Address:
554 W BENTON ST
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:
83204-3349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-971-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2018