Provider First Line Business Practice Location Address:
115 S 15TH AVE STE C
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:
83201-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-7558
Provider Business Practice Location Address Fax Number:
208-232-7549
Provider Enumeration Date:
04/21/2014