Provider First Line Business Practice Location Address:
1125 W ALAMEDA 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:
83201-6143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-1151
Provider Business Practice Location Address Fax Number:
208-237-9721
Provider Enumeration Date:
07/14/2005