Provider First Line Business Practice Location Address:
716 YELLOWSTONE 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:
83201-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-5437
Provider Business Practice Location Address Fax Number:
208-232-5490
Provider Enumeration Date:
09/22/2011