Provider First Line Business Practice Location Address:
1449 PARAMOUNT ST
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:
83201-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-270-1309
Provider Business Practice Location Address Fax Number:
208-684-7823
Provider Enumeration Date:
06/25/2024