Provider First Line Business Practice Location Address:
500 S 11TH AVE STE 201
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:
83201-4878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-1984
Provider Business Practice Location Address Fax Number:
208-234-1987
Provider Enumeration Date:
10/26/2006