Provider First Line Business Practice Location Address:
845 W CENTER ST
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:
83204-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-729-6041
Provider Business Practice Location Address Fax Number:
208-992-0241
Provider Enumeration Date:
10/17/2024