Provider First Line Business Practice Location Address:
1000 N 8TH AVE
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:
83201-5757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-3369
Provider Business Practice Location Address Fax Number:
208-776-5016
Provider Enumeration Date:
07/31/2014