Provider First Line Business Practice Location Address:
333 WEST CEDAR
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:
83201-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-6912
Provider Business Practice Location Address Fax Number:
208-233-6921
Provider Enumeration Date:
10/03/2006