Provider First Line Business Practice Location Address:
210 E CENTER ST 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:
83201-6352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-2600
Provider Business Practice Location Address Fax Number:
208-234-2800
Provider Enumeration Date:
11/20/2017