Provider First Line Business Practice Location Address:
ISU BOX 8357
Provider Second Line Business Practice Location Address:
465 MEMORIAL DRIVE
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-4508
Provider Business Practice Location Address Fax Number:
208-282-4818
Provider Enumeration Date:
08/17/2005