Provider First Line Business Practice Location Address:
330 E 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:
83201-6526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-0651
Provider Business Practice Location Address Fax Number:
208-478-1731
Provider Enumeration Date:
01/11/2024