Provider First Line Business Practice Location Address:
353 E LANDER ST
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:
83201-6314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-2380
Provider Business Practice Location Address Fax Number:
208-234-8040
Provider Enumeration Date:
01/08/2015