Provider First Line Business Practice Location Address:
1033 W QUINN RD
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:
83202-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-4579
Provider Business Practice Location Address Fax Number:
208-233-4887
Provider Enumeration Date:
10/23/2006