Provider First Line Business Practice Location Address:
1355 E CENTER 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:
83201-4737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-9355
Provider Business Practice Location Address Fax Number:
208-233-1200
Provider Enumeration Date:
10/04/2007