Provider First Line Business Practice Location Address:
155 S 2ND AVE
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:
83201-6407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-271-6389
Provider Business Practice Location Address Fax Number:
208-646-4415
Provider Enumeration Date:
07/05/2024