Provider First Line Business Practice Location Address:
275 S. 5TH AVE.
Provider Second Line Business Practice Location Address:
STE. 140
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-4267
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2006