Provider First Line Business Practice Location Address:
560 MEMORIAL DR STE B
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:
83201-4073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-0258
Provider Business Practice Location Address Fax Number:
208-269-7336
Provider Enumeration Date:
08/21/2009