Provider First Line Business Practice Location Address:
850 YELLOWSTONE AVE 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:
83201-4415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-8066
Provider Business Practice Location Address Fax Number:
208-239-8067
Provider Enumeration Date:
05/06/2021