Provider First Line Business Practice Location Address:
2302 E TERRY 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:
83201-2733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-235-5910
Provider Business Practice Location Address Fax Number:
208-235-5920
Provider Enumeration Date:
11/20/2015