Provider First Line Business Practice Location Address:
209 E LEWIS ST 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:
83201-6465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-7693
Provider Business Practice Location Address Fax Number:
208-232-9362
Provider Enumeration Date:
11/18/2024