Provider First Line Business Practice Location Address:
1133 N MAIN ST
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:
83204-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-9361
Provider Business Practice Location Address Fax Number:
208-236-1855
Provider Enumeration Date:
04/06/2007