Provider First Line Business Practice Location Address:
427 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83204-3016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-242-3771
Provider Business Practice Location Address Fax Number:
208-242-3772
Provider Enumeration Date:
06/08/2011