Provider First Line Business Practice Location Address:
1777 E CLARK ST
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-5433
Provider Business Practice Location Address Fax Number:
877-284-2783
Provider Enumeration Date:
07/07/2010