Provider First Line Business Practice Location Address:
289 JEFFERSON 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:
83201-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-5600
Provider Business Practice Location Address Fax Number:
208-233-5800
Provider Enumeration Date:
12/20/2006