Provider First Line Business Practice Location Address:
1950 E CLARK ST STE 110
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:
83201-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-252-5021
Provider Business Practice Location Address Fax Number:
208-205-8040
Provider Enumeration Date:
02/01/2022