Provider First Line Business Practice Location Address:
275 SOUTH 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-2506
Provider Business Practice Location Address Fax Number:
208-478-9558
Provider Enumeration Date:
02/27/2007