Provider First Line Business Practice Location Address:
155 S 2ND AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-261-4233
Provider Business Practice Location Address Fax Number:
833-471-4276
Provider Enumeration Date:
11/02/2006