Provider First Line Business Practice Location Address:
335 E LEWIS ST
Provider Second Line Business Practice Location Address:
STE 10
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-269-2360
Provider Business Practice Location Address Fax Number:
208-550-3256
Provider Enumeration Date:
06/09/2011