Provider First Line Business Practice Location Address:
101 SOUTH MAIN STREET
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:
83204-4321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-8840
Provider Business Practice Location Address Fax Number:
208-232-0925
Provider Enumeration Date:
09/25/2013