Provider First Line Business Practice Location Address:
650 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
BLDG 68
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83209-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-2190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006