Provider First Line Business Practice Location Address:
1440 E TERRY ST
Provider Second Line Business Practice Location Address:
BLDG 63
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-8120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-960-0452
Provider Business Practice Location Address Fax Number:
208-282-2583
Provider Enumeration Date:
01/07/2014