Provider First Line Business Practice Location Address:
650 MEMORIAL DRIVE BUILDING 68
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:
83209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-3495
Provider Business Practice Location Address Fax Number:
208-282-4571
Provider Enumeration Date:
07/25/2011