Provider First Line Business Practice Location Address:
240 N 18TH AVE STE 2
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:
83201-3324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-5550
Provider Business Practice Location Address Fax Number:
208-232-5553
Provider Enumeration Date:
08/31/2006